Pulmonary and Medicine Associates

27472 Schoenherr Rd, Suite 100, Warren MI 48088
Phone: 586-751-8844
WORKER'S COMP ACCIDENT INSURANCE QUESTIONARE
Must be completely filled out in order to process claims
  • I authorize the release of any medical information necessary to process this claim.
  • I permit a copy of this authorization to be used in place of the original.
  • I hereby authorize Pulmonary and Medicine Associates, PLLC to submit claims on my behalf for services rendered.
  • I authorize that those payments from my insurance company be made directly to Pulmonary and Medicine Associates, PLLC.
  • I certify that the information I have provided is correct

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